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Dec 04 02 10:27a 5592 70106 p.2 <br />SFRYfCE REQUEST <br />I FACILITY 10 # <br />Type of Business or Property Ir) r) ,•,� 1 <br />OWNER I OP <br />FAC¢rrYNAME <br />SITE ADDRESS <br />Mailing Address (if WellntSS•troc m Site Address <br />CTTY L—C)OU -7A NO <br />TEXr- AP <br />PHONE{fI �����C014T�KACTOR <br />�� <br />� 3� �SERA� <br />REOUESTOR <br />BUSINESS NAME; <br />MAILING ADURE�J I n Q q <br />SER�YICE REI 5 <br />0 <br />BILLING <br />TYr» Suit.2 <br />STS <br />LAND USE AFPLr-ATION# <br />LOCATION CODE <br />SIttING PARTY 0 <br />ter. <br />PNON <br />E # <br />FAx#.� <br />v <br />CITY owtedge that au site andlor Prnjed speGfx <br />`� for or authoraed agent of same. adut as ident$xd on th"s loMm <br />ned proper,y or business owner, ops « h be billed to me or my business <br />BILLING ACKNOWLEDGEMeNT: G he undersg assoaahed with this prof Codes Standards, STATE and <br />CES ENVPiCt+►aENTAt HEAL'M DMSCN hourly, d_g Oe W11tt all SAN JOACUN Col Or&anw <br />PUBLIC HEALTH 5&Tn ed wa be done in acwrdan <br />Ct6 application and ttui the wo k m be perform 1 <br />I also certify mat I have RmPa _ b! �- <br />FEDERAL'Z-- <br />APPA WMT SIGMATUI I OTHER AUTHOR��-D AGENT Ti rle <br />OPERATOR 1 h1►NAGER /� er+etlrorintlart ro siya b +*Qv� C1e release of <br />PRo9ERT�' I gUS1NESS C I" F ❑ nA p_rwr a ro me Qom?" ted at fie above ide address. hereby aulhorme as soon <br />AUTHORIZATI N TO RELEASE INFORMA N: When applicable. I °rope <br />rater of the propertlf �HEALTH SERVI S EWRO WETAL HEAL -,H DMSION <br />i eotedMn cal data andlor em conmenraVs to assessment infannation m C e SAN JOADUW CWNTY PUBLIC <br />any and all esu ts. g reserriattve• <br />as it Is avaJable and at the same time A is Pied -e <br />COMMENTS: or rry rep <br />TYPE OF SERVICEREQUESTEO: lr j / T )C <br />COMMENTS: !l <br />GOVN <br />cpN`pHtiP� 1EPRNO0g101y <br />POg MEN�'t <br />FN��RON <br />Q0NTKAGlUM---- 12 <br />MDATE <br />INSPECTOR'S SIGMA NE: ' EypL^ mg4-1 <br />APPROVED 8Y:11 <br />( DATE: ' <br />r. FypLDYEEii: (i C1 �_� L� 'P�E�Z-3® <br />ASSiGMEnTn: v�j h a_ SENVIc£CoDE t <br />Date Service Completed (if already compfatedj' payment Date <br />Amount Paid 21.i � Received By: <br />Fee AMO 111 2� -7 Check A <br />Invoice if <br />Payment Type <br />